CMS’ Physician QRUR Tables Highlight High-Value Referral Patterns for Medicare Population

William HoldingAmong other data, detail tables in a physician practice’s Quality Use and Resource Reports (QRURs) pinpoint specialist referral networks for Medicare beneficiaries, explains William Holding, consultant, PDA, Inc., which can help physician practices determine their highest value referral pathways.

In this audio interview, Holding explains the benefits of tapping CMS-generated QRUR reports to enhance performance under Merit-Based Incentive Payment Systems (MIPS), one of two payment paths for physician reimbursement under MACRA.

During Physician MACRA Preparation: Using QRUR and Other CMS Data To Maximize Your Performance, a January 2017 webinar now available for replay, Holding and colleague Nancy Lane, president of PDA, Inc., share the critical steps physician practices should take when analyzing their QRUR data, along with details on other CMS data points that can help practices improve MIPS performance.


Length: 3:07 minutes

MACRA for Small Physician Practices: Don’t Let the Technology Intimidate You

Eric LevinRather than threatening to drop Medicare volumes or open a concierge practice, small and solo physician practices daunted by MACRA technology requirements should sit tight and avail themselves of current and promised education and training from CMS to support the transition, advises Eric Levin, director of strategic services, McKesson.

In this audio interview, Levin describes what’s at risk for practices that don’t engage in at least one physician reporting program and four benefits of tapping into MACRA technical assistance from CMS.

During a July 2016 webinar, The New Physician Quality Reporting: Positioning Your Practice for MACRA’s Merit-Based Incentive Program, now available for replay, Levin offers a brief MACRA overview and outlines 2016 focus areas for practices to help them avoid reimbursement penalties in 2017 based on the proposed rule.


Length: 4:00 minutes

Horizon BCBSNJ Episodes of Care: No-Risk Retrospective Model Paves Way for Value-Based Migration

Lili BrillsteinWhile it does not immediately eliminate fee for service, a retrospective upside-only payment model is helping to transform the spirit of the payor-provider relationship, notes Lili Brillstein, director of the Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ) Episodes of Care (EOC) initiative where this methodology has been implemented.

Listen as Ms. Brillstein describes how Horizon’s application of retrospective methodology across all episodes expands the program’s reach and opportunities while fostering a no-risk environment conducive to collaboration.

During a March 2016 webinar, Episodes of Care: Improving Clinical Outcomes and Reducing Total Cost of Care Through a Collaborative Payor-Provider Relationship, now available for replay, Ms. Brillstein shares details behind the health plan’s EOC program, from the episodes they have bundled to goals and results from the program.


Length: 4:12 minutes

Next Generation Healthcare Nurse Navigators: The Advantages That Won Over ‘Solo Cowboy’ Practitioners

Robert FortiniWhen Bon Secours adapted Geisinger’s case management model six years ago and embedded nurse navigators within physician practices, there was reluctance and even resistance from some “solo cowboy” physician practitioners, recalls Robert Fortini, PNP, chief clinical officer for Bon Secours Medical Group. Today, providers are fiercely protective of the cadre of 70 nurse navigators, who do the “heavy lifting” of chronic care management.

In this audio interview, Fortini offers some lessons learned for organizations considering the embedded case management approach, including budgetary planning, calculations, and “icing-on-the-cake” outcomes for patients and hospitals.

During a January 2016 webinar, Physician Reimbursement in 2016: Workflow Optimization for Chronic Care Management and Advance Care Planning, now available for replay, Fortini offered an inside look at Bon Secours’ experience with CMS’ chronic care management reimbursement in 2015 and how they leverage this experience for CMS’s newest billable event in 2016—advance care planning.


Length: 3:24 minutes

Road Shows, Report Cards Engage Providers in Top-Performing Medicare Pioneer ACO

Kelly ClementsPhysician engagement is one of three top challenges of the Medicare Pioneer ACO model, along with performance improvement and care management, explains Kelly Clements, Pioneer program director for Steward Health Care Network, which operates Promise, a top-performer in CMS’s Medicare Pioneer ACO program.

To drive engagement in its accountable care organization at the provider level, Steward offers a range of physician tools and supports, including road shows and report cards, which Ms. Clements describes in this audio interview.

During a June 2015 webinar, Medicare Pioneer ACO: Care Management, Quality Improvement and Data Integration Yields Substantial Performance Gains, now available for replay, Kelly Clements shares her organization’s Pioneer ACO Program experience over the first three Pioneer performance years and how Steward leverages this experience with other risk-based contracts, including the newly announced CMS Next Generation ACO Model.


Length: 4:09 minutes

Payoffs from Patient Care Plans and Goal-Setting in Chronic Care Management

Debra BurbaryWhen Arcturus Health Care did the math, CMS’s new Chronic Care Management (CCM) code added up to a potential $100,000 per month in revenue for its four physician practices, or $1 million annually. Having successfully billed Medicare for a half dozen patients enrolled in CCM, Arcturus’s Clinical Quality Assurance Manager Debra Burbary, RN, outlines development of the patient care plan and establishment of patient goals—two CCM requirements facilitated by Arcturus’s electronic health record (EHR).

During a May 2015 webinar, Medicare Chronic Care Management Billing: Leveraging Population Health Management for Successful Claim Submission, now available for replay, Ms. Burbary shares her organization’s approach to care management of high-risk patients and billing for chronic care management.


Length: 4:04 minutes

Healthcare’s Volume-to-Value Transition: How to Get Paid While You’re Waiting

Jennifer SeidenDespite CMS’s aggressive agenda for moving Medicare to a value-based payment structure, it will take time before alternative reimbursement approaches are adopted across the healthcare continuum. So how can healthcare get paid in the meantime?

During the February 5, 2015 webinar, Positioning for Value-Based Reimbursement: Workforce Development for Transitional Care, Chronic Care Management, Jennifer Seiden, administrative director, population health, Bon Secours Medical Group, described how her organization is making the most of the industry’s transition from volume to value.

During the 45-minute program, now available as on on-demand replay, Ms. Seiden and Lu Bowman, population health market program manager for Bon Secours Medical Group, shared how Bon Secours is developing the professional skill sets needed to adapt to new care delivery and reimbursement opportunities. The program was sponsored by the Healthcare Intelligence Network.


Length: 2:59 minutes

Hybrid Embedded RN Care Managers Target High-Cost, High-Utilization ‘VIPs’

When Sentara Medical Group determined its embedded RN care managers spent only 25 percent of their time on care management, it revamped its embedded model, explains Mary M. Morin, RN, NEA-BC, RN-BC, nurse executive with Sentara. In the new hybrid model, RN care managers support two to three practices and also visit high-cost, high-utilization patients at home, in the hospital and virtually.

At first, Sentara management balked at a perceived duplication of service between the RNs and home health nurses—until they saw the fruits of these patient encounters, which Ms. Morin describes in this audio interview. Home visits in particular allow RN care managers to assess the patient’s environment and meet the individual on their level, which lifts engagement in self-care, she notes.

Mary Morin will explain the motivation behind Sentara’s hybrid embedded case management model and the model’s impact on its highest risk population during a July 31, 2014 webinar, “A Hybrid Embedded Case Management Model: Sentara Medical Group’s Approach,” a 45-minute program sponsored by The Healthcare Intelligence Network.


Length: 8:28 minutes

Aligning Value-Based Reimbursement with Physician Practice Transformation

In its quest to transform 70 to 80 percent of its physician practices to a patient-centered medical home (PCMH) over the next three years, WellPoint has adopted a “meet the practices where they are” philosophy, reports Julie Schilz, director of care delivery transformation for WellPoint. Each practice is at a different place in the transformation effort and requires specialized supports, she adds.

Smoothing the transformation rollout is the simultaneous participation of 500 WellPoint practices in CMS’s Comprehensive Primary Care (CPC) program, whose goals dovetail with key PCMH principles — as though WellPoint had another partner in its transformation initiative, Schilz notes.

Just as important as practice support is transparency with health plan members, Schilz adds, especially when it comes to explaining the concept of the medical home neighborhood — where care coordination is a collaboration between primary care and the specialist.

Ms. Schilz shared the key features of WellPoint’s transformation initiative, including results from its pilot program that have led to a system-wide rollout, during an October 24, 2013 webinar, Aligning Value-Based Reimbursement with Physician Practice Transformation.


Length: 5:29 minutes